The Commissioner: STPs have fallen short, and time is running out

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What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West

We’re calling it: All 44 sustainability and transformation plans areas have published a version of their full plan.

This is in large part a case of having hit the target to publish, but missing the point. A stage managed publication process became necessary to try to draw out the venom of public suspicion: nobody thinks many of these documents are the finished article.

They are better judged by what they don’t say than what they do: important long-standing issues going unmentioned; vital detail for delivery left absent; and a lack of agreed numbers to underpin contracts and financial balance in the next two years.

On the first, there are countless examples. In Lancashire, “everybody in the region knows major reconfiguration is needed across acute and specialist services”, but it is dodged in the STP.

In Bristol, the published plan doesn’t deal with the pressing issues of trust and CCG-side consolidation, while in Somerset there is no mention of the two general acute trusts coming together. One STP leader privately tells how, after months of niceties, they are still unable to even raise a long overdue stroke reconfiguration across general hospitals in their patch.

On the second point, few of those working on STPs profess huge confidence in the detail of delivery. NHS England has said STPs are “understandably a work in progress”, while a fairly sober assessment by NHS Improvement finance chief Bob Alexander notes that STPs’ high ambitions of controlling hospital activity (on which their financials rest) “will be highly challenging for most STP areas”. All this is despite the very time-pressured hard work of the best people willing to do the work locally.

When it comes to doing deals for 2017-19 and financial delivery, for many – surprise, surprise – the contracting round has triggered the familiar big rows, bigger cash gaps and mixed messages from above about whether it is STP ambition or providers’ pressures which take precedent. There are some areas, in fairness, which are moving more amicably towards agreement, and hope to be in line for a system control total – it looks like they will wait until next year before finding out if they can.

What next then?

Simon Stevens has rebadged STPs as “proposals” – in nearly all cases they are yet to qualify as “plans”.

From a pragmatic point of view, each area needs to find a way to settle their leadership and capacity, accelerate the conversations that have at least now begun, take another run at dealing with the big changes and detailed delivery, and perhaps shake off the tarnished “STP” label while getting some people onside. This type of work is nothing new, though it now has to happen in an extreme climate.

The macro picture is uglier. The longer STPs remain “works in progress”, the longer we’re without a model under which the NHS can balance its budget – and it is fast running out of road before the tightest years of funding famine, from 2018 to 2020.

The fact STPs have fallen short of expectations will have disappointed some important people. In his formal note of concern on the NHS’s accounts last year, with which many in government will concur, the auditor general called for “a robust, credible and comprehensive plan to move the NHS to a more sustainable financial footing”. He didn’t demand a set of well intentioned but highly variable “proposals”.

Mr Stevens will seek to use a “forward view delivery plan” in March (post-winter, pre-end of year financials) to demonstrate the NHS is still on course.

The Commissioner reading list: The good, the bad and the ‘fully integrated’

A lot of people are asking which STPs are good and which bad. It’s hard to judge since the important things are, as per the above, often unwritten. The centre has opted for now not to rate them publicly - it would look pretty bad with so few in the “good” category.

Devon, Essex and possibly Cumbria have made strides off the back of the “success regime”. Dorset has a good plan and strong local leadership, that’s gone to consultation. South Yorkshire - led by giant of his region Sir Andrew Cash - is well looked upon, though its document itself may disappoint. The Black Country and West Birmingham has a heady cocktail of three strong integration models across Dudley, Wolverhampton and Sandwell, and admirers in high places. We thought Derbyshire had a good and realistic plan; and Nottinghamshire a heartening blend of honesty and outward-looking commitments on public health.

Frimley Health remains the golden boy, with Simon Stevens suggesting it becomes an “integrated organisation”. Whether Frimley agrees is a different question - sorting this out is as sensitive and complicated as ever, and Mr Stevens landed Royal Free’s David Sloman in trouble with colleagues with a similar comment in the summer. The centre hopes there will be a small number of other areas able to move this status of “combining the purchaser and provider” - there is a desire for some “PACS” trusts to embrace their wider STP. I ran some numbers to see which footprints, like Frimley, have very strong reliance on a single acute provider, like Frimley. Often the trust is not in miles from being able to do so (Shrewsbury and Telford, Royal Cornwall); in all cases it would not be straightforward - within reach of plausibility may be Royal Free (group), Nottingham, Lincolnshire, Basildon with Mid Essex, and Somerset.

And which STPs are firmly on the naughty step? Staffordshire is the last to publish - it has notorious relationship problems, performance problems, and just seen a change of chief exec at its main acute. It was a considered for the success regime last summer, as was Kent, whose STP work has also been tumultuous and seems to have drafted in Dame Ruth “walking success regime” Carnall. Hertfordshire was very late publishing, has changed its leader, and doesn’t seem to be holding things together; Nene was late as well; while Shropshire and Telford is midway through a nasty and chaotic reconfiguration battle, so probably isn’t the place to look for your future. Or, is precisely the place.

Would you like to argue your STP is good, bad or about to become “fully integrated”? Get in touch.